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August 2010

Spotlight Summary by Summer Gibbs-Strauss

Near-infrared (NIR) imaging is an active area of research that has not yet fully realized its clinical potential. NIR imaging is currently being explored for image-guided surgery, breast cancer, brain, and lymphatic imaging as well as imaging of edoscopically accessible tissues. Clinical translation of NIR imaging will require both validated imaging systems and FDA-approved contrast agents. Currently there are only two FDA-approved fluorophores: indocyanine green (ICG) and methylene blue. Clinical proof of concept using either FDA-approved fluorophore will provide the most efficient path to the clinic for NIR imaging.

Breast cancer survival has significantly increased in the U.S. owing to earlier diagnosis and aggressive therapy. Surgical intervention for breast cancer, including lumptectomy and mastectomy to remove the tumor mass as well as sentinel and axillary lymph-node dissection to assess tumor stage and need for additional treatment, is standard of care. However, nodal staging also increases risk of breast-cancer-related-lymphedema (BCRL), a currently underrecognized side effect of curative breast cancer surgery. Lymphedema affects up to 50% of breast cancer survivors and can be compounded by radiation therapy, which is often used in concert with surgical intervention for curative therapy. Lymphedema is managed through complete decongestive therapy, which includes manual lymphatic drainage, compression bandages, and therapeutic exercise. Pneumatic compression devices (PCD) have been proposed for continued lymphedema management but are currently not standard management of the disease. Use of PCD in standard management of lymphedema is controversial because there is no method to directly assess patient benefit. Currently, lymphedema treatment efficacy is assessed over several weeks by quantifying arm volume as measured through changes in circumferential arm size or water displacement.

In the work published here by Adams et al., the use of a NIR imaging system to visualize ICG for real-time lymphatic tracking is tested in a phase I clinical trial to assess lymphatic response to PCD therapy. NIR imaging enabled visualization of lymphatic flow and subsequent quantification of lymphatic propulsion and velocity. This phase I NIR imaging study quantified the lymphatic propulsion and velocity before, during, and after treatment with PCD in normal subjects and BCRL patients. Quantification of NIR images showed increased frequency of lymph propulsion and proximal movement of ICG in the lymph, resulting in improved lymphatic function in the symptomatic arms of 4 of 6 BCRL patients. Continued use of PCD for lymphedema management could improve lymphatic function in BCRL patients warranting additional clinical trials. Furthermore, longitudinal NIR imaging studies could also improve understanding of the onset and management of BCRL, aiding development of future therapeutic strategies.